A nurse is continuously monitoring a client who is receiving an intravenous infusion of doxorubicin, a known vesicant, via a peripheral catheter. The client suddenly reports severe burning pain at the insertion site, and the nurse observes localized swelling and erythema. To reduce the risk of severe tissue necrosis, in what order should the nurse perform the following interventions?
- 1Stop the intravenous infusion of the vesicant medication immediately.
- 2Disconnect the intravenous administration set from the catheter hub.
- 3Attach a small sterile syringe to the catheter hub and aspirate any residual medication.
- 4Remove the peripheral intravenous catheter.
- 5Elevate the affected extremity and apply a cold compress to the site.
Answer
The correct sequence is to first stop the infusion, then disconnect the IV tubing, aspirate residual medication from the catheter, remove the IV catheter, and finally elevate the extremity and apply a cold compress.
The sequence follows the standard oncology protocol for vesicant extravasation: immediately stop the infusion to prevent further harm, disconnect the line, leave the cannula in place temporarily to aspirate residual drug from the subcutaneous pocket, remove the cannula, and apply appropriate thermal therapy (cold for doxorubicin) to localize the drug.
Step-by-Step Solution
Key Concept
Management of Vesicant Extravasation to Reduce Tissue Necrosis Risk